"ADHD was a risk factor for suicide attempt"

The findings reported by Kai-Lin Huang and colleagues [1] continue an important research theme (see here) on how a diagnosis of attention-deficit hyperactivity disorder (ADHD) may increase the risk of suicidal behaviours (see here). Further, that timely management of the symptoms of ADHD via indicated pharmacological means in particular, may provide some important risk-reduction from such behaviours; again substantiating previous investigations in this area (see here).

Based, yet again, on the fabulous but now sadly non-functional resource that is/was the National Health Insurance Research Database (NHIRD) in Taiwan, researchers undertook a "longitudinal cohort study [that] enrolled 20 574 adolescents and young adults with ADHD and 61 722 age- and gender-matched controls between 2001 and 2009." This is yet another example of Taiwanese 'big data' in action on the important topic of suicide (see here and see here). Alongside detailing any psychiatric comorbidities accompanying the diagnosis of ADHD, Huang and colleagues looked for diagnostic codes indicating suicide attempt(s) and whether or not medication(s) clinically indicated for ADHD were prescribed.

Results: "ADHD was an independent and direct risk factor for any suicide attempt, and an even stronger risk factor for repeated suicide attempts." As per my previous blogging forays into this topic, such news is by no means novel. The use of "long-term methylphenidate treatment" being associated with "a significantly decreased risk of repeated suicide attempts in men with ADHD" is also not new news, but does once more, provide yet more evidence for the use of such strategies and their seeming effects well beyond just symptom reduction/management.

What's more to say? Well, one might need to delve a little more into what it is about ADHD that *might* predispose to such extremes of behaviour. Whether this be a heightened risk of other comorbidity occurring as a function of ADHD (see here) impacting on suicidal behaviour(s) or something rather more directly linked to ADHD (see here), there is a schedule of further research to continue. I'm also minded to direct your attention to the findings reported by Mars and colleagues [2] and how general population 'risk factors' might also provide some clues. Minus any medical or clinical advice given or intended, I'll reiterate how the use of something like lithium seems to be quite useful in the context of potentially reducing suicide risk (see here) and how further work perhaps needs to be done on this compound with specific focus on suicide risk and ADHD. I say this, bearing in mind that lithium has a risk profile of its own.

Oh, and need I remind you that ADHD as being an 'over-represented' feature of autism for quite a few people (see here) might also imply some 'association' in the very serious statistics talking about suicide risk in the context of autism (see here)...

Again, if anyone needs to talk to someone, there are organisations out there willing to listen.

----------

[1] Huang KL. et al. Risk of suicide attempts in adolescents and young adults with attention-deficit hyperactivity disorder: a nationwide longitudinal study. Br J Psychiatry. 2018 Mar 4:1-5.

[2] Mars B. et al. What distinguishes adolescents with suicidal thoughts from those who have attempted suicide? A population-based birth cohort study. J Child Psychol Psychiatry. 2018 Mar 1.

----------

Vitamin D impacts on intestinal inflammation in 'active' ulcerative colitis: an autism research agenda item?

The results reported by Mayur Garg and colleagues [1] are slightly outside of the typical remit of this blog primarily focused on autism research, but give me a minute or two and I'll hopefully bring them back into the [research] fold.

Garg et al published findings looking at what effect (if any) a quite large dose of vitamin D delivered over 8 weeks might have in relation to a small group of participants "with active UC [ulcerative colitis],... with inactive UC and... non-IBD [inflammatory bowel disease] controls." They concluded that said intervention - "40,000 [international] units cholecalciferol weekly for 8 weeks" - (a) was associated with an increase in functional levels of vitamin D as would be envisaged, (b) *correlated* with a reduction in one measure of inflammation commonly used to grade the activity of UC (faecal calprotectin) and (c) did not seem to significantly impact on various measures examined in inactive and/or non-IBD participants. They concluded that: "Vitamin D supplementation was associated with reduced intestinal inflammation in patients with active UC" with the requirement for much more investigation in this area.

What's the possible autism link? Well, minus too many sweeping generalisations, there may be quite a few. First are the observations that IBDs such as UC may well be 'over-represented' when it comes to the label of autism (see here and see here). I know such findings might have the ability to furrow brows when it comes to autism research history (see here for example) but there is a clinical need for greater screening (and treatment) efforts when it comes to such IBDs in the context of autism. I'd also mention that faecal calprotectin in a 'low-grade intestinal inflammation' sense, has been discussed before on this blog (see here). Second, vitamin D is also a topic of growing interest when it comes to autism (see here and see here for examples). We can um-and-ah about whether such reports of deficiency/insufficiency in the context of autism are 'autism-specific' or just following the trends noted in various other populations (see here and see here). But that does not alter the vitamin D findings observed across various populations and studies with autism in mind. Adding the two observations together in the context that vitamin D deficiency is likely to affect more than just bone metabolism (something else noted in relation to some autism) and one arrives at the possibility that autism + inflammatory bowel disease (specifically UC, and active UC) *might* be something to look at with vitamin D supplementation in mind. Might...

Music, and my brood have finally bumped into the Greatest Showman, and one song seems to be a particular favourite...

----------

[1] Garg M. et al. The effect of vitamin D on intestinal inflammation and faecal microbiota in patients with ulcerative colitis. J Crohns Colitis. 2018 May 3.

----------

"children with both ASD and subclinical autistic traits have lower neuropsychological performance"

The quote heading this post - "children with both ASD [autism spectrum disorder] and subclinical autistic traits have lower neuropsychological performance" - comes from the findings reported by Fjola Hyseni and colleagues [1].

Researchers report results from a study "embedded in the Generation R Study" (an initiative that has appeared before on this blog) examining whether neuropsychological performance as measured by "using subtests of the NEPSY-II-NL" showed any connection to autistic signs and symptoms. The sorts of things looked at via the NEPSY-II included "attention and executive functioning, memory and learning, sensorimotor, language, and the visuospatial domain."

Actually, the Hyseni study was a multi-factorial study in that their analysis "involved an ASD case versus control analysis comparing children with a diagnosis of ASD to children without an ASD diagnosis" and also "to test for a linear relationship between autistic traits and NEPSY-II performance in the entire sample." Finally, they "excluded both children with a diagnosis of ASD and children with high autistic symptoms" but still looked at scores on the Social Responsiveness Scale (SRS) as a function of NEPSY-II test performance.

Results: based on the inclusion of data from over 1000 children, there were some important details attached to the authors observation that autistic traits were negatively correlated with neuropsychological performance. So, as well as higher levels of autistic traits or a diagnosis of autism being associated with lower neuropsychological performance across various domains and taking into account various other potential confounding variables - covariates - (gender, age, ethnicity, child attention problems, etc), so those analyses of SRS scores of participants without a diagnosis of autism or high autistic traits yielded important findings. For the 960 children who this covered, authors reported that "the significant relationship between SRS scores and neuropsychological performance remained", at least when it came to memory and learning, sensorimotor functioning, and language domains following adjustment for those covariates. The authors conclude that: "Our results provide support for a relationship along the continuum between autistic symptoms and neuropsychological performance in school-age children who encompass children with subclinical autistic traits." Further investigations are implied in this area on the basis for example, that: "the measurements of autistic traits, neuropsychological functioning, and IQ were not performed at the same time; thus, there was a short time difference between the two measurements."

There are some important implications from such results. Not least, as the authors point out: "children with both ASD and subclinical autistic traits have lower neuropsychological performance" and also that they: "may provide an understanding of why some children without an ASD diagnosis may require some additional assistance within academic settings." I hasten to add that neuropsychological performance is not necessarily the same as academic performance, and so one has to be quite careful of where such discussions could lead. I also think back to those ideas that have perpetuated autism down the ages suggesting that a diagnosis of autism confers some sort of 'savant' advantage to the masses. I've talked before about how sweeping a generalisation such thinking is (see here) and indeed, the Hyseni findings kinda add further cold water to such universal sentiments. People diagnosed as on the autism spectrum are gifted in many ways, but not necessarily because of any diagnostic label they have received and not necessarily consistently so [2]...

And on the topic of autistic traits potentially 'influencing' performance, the findings reported by Crehan and colleagues [3], including one John Constantino - "the authors of the SRS" - are also pertinent. To quote: "Splitting the SRS scores into three severity classes revealed that impaired social responsiveness is significantly related to competency." One also has to wonder in the longer term, whether the sentiments expressed by Skylark & Baron-Cohen [4] on how certain autistic traits (particularly socially implicated traits) might "influence a person’s financial circumstances" could also 'interact' with the findings being discussed.

Much food for thought.

----------

[1] Hyseni F. et al. Autistic traits and neuropsychological performance in 6- to-10-year-old children: a population-based study. Child Neuropsychol. 2018 Apr 23:1-18.

[2] Lindor E. et al. Superior Visual Search and Crowding Abilities Are Not Characteristic of All Individuals on the Autism Spectrum. J Autism Dev Disord. 2018. May 22.

[3] Crehan ET. et al. Tracking the Influence of Autistic Traits on Competencies Among School Aged Children with Subthreshold Autistic Traits: A Longitudinal Study. Child Psychiatry Hum Dev. 2018 May 11.

[4] Skylark WJ. & Baron-Cohen S. Initial evidence that non-clinical autistic traits are associated with lower income. Mol Autism. 2017 Nov 13;8:61.

----------

EarlyBird and EarlyBird Plus and autism: good acceptability but "lower level evidence of efficacy"

EarlyBird and EarlyBird Plus feature quite regularly here in the UK. The UK National Autistic Society (NAS) promote them as strategies to "support parents in the period between diagnosis and school placement" and "empowering and helping them facilitate their child's social communication and appropriate behaviour in their natural environment." There is even use of the term 'good practice' as part of the evidence-based implementation of such strategies.

The results of the 'scoping review' published by John-Joe Dawson-Squibb and colleagues [1] however, suggest that whilst there may be some benefits to parents of children diagnosed with autism or autism spectrum disorder (ASD), there is still a scheme of work to follow when it comes to EarlyBird and EarlyBird Plus in terms of their scientific evidence of effect. Namely that "lower level evidence of efficacy of EarlyBird/EarlyBird Plus was found" following their review of the current peer-reviewed science. Quite a few more resources might therefore be needed to be ploughed into things like randomised-controlled trials of EarlyBird and EarlyBird Plus.

I'm careful here not to poo-poo such programmes and their potentially important effect(s), despite the fact that the science is not yet 'complete' in this area. For many families following the conclusion of the diagnostic process for their child/children, such programmes offer an important 'where next?' option that should not be under-estimated (see here) in relation to the journey they face post-diagnosis.

But at the same time, I think there are lessons to be learned. Drawing for example, on the area of parent-mediated intervention(s) that has been a strong research and practice focus down the years, we've started to reach a point where the evidence is not overwhelming in terms of positive effects when it comes to outcomes for the children themselves, bearing in mind the range of different programmes offered under such descriptions. Again, there are lots of very positive things said about such interventions by parents and guardians, but when it comes to the children, and important longer-term outcomes for them, quite a bit more rigorous scientific inquiry is required to ensure that it works for them too. The same should probably apply to EarlyBird and EarlyBird Plus too to ensure that what is being offered is not just based on 'anecdote' and 'belief' but rather good solid, 'controlled' scientific evidence. The same sort of evidence that is asked of many different 'intervention approaches' in the context of autism. Indeed, as also mentioned by the authors - "we recommend broader feasibility evaluation of EarlyBird/EarlyBird Plus including accessibility, cultural appropriateness and scalability" - further evidence is required to ensure that it caters to the needs of all parents across many various demographic differences...

Music to close: an oldie but still a goodie...

----------

[1] Dawson-Squibb JJ. et al. Scoping the evidence for EarlyBird and EarlyBird Plus, two United Kingdom-developed parent education training programmes for autism spectrum disorder. Autism. 2018 Mar 1:1362361318760295.

----------

Vitamin D deficiency in adult patients admitted to a psychiatric ward: same as before

The 'same as before' part of the title of this post refers to the observation that vitamin D deficiency is not an uncommon feature for those admitted to psychiatric hospitals (see here and see here).

This time around I present the results published by Dipen Patel & Manjunath Minajagi [1] who reported that: "49% (N = 51) of participants were vitamin D deficient (serum 25(OH)D <30 nmol/L), and a further 42% (N = 44) were vitamin D insufficient (<50 nmol/L); 8.7% (N = 9) of participants were vitamin D sufficient (>50 nmol/L)."

'Participants' mentioned by Patel & Minajagi, referred to 104 adults (average age of 40) admitted to a psychiatric hospital who provided written consent to participate in their study and were diagnosed with a range of psychiatric disorders including "depressive episode", "bipolar affective disorder", "schizophrenia" and/or "personality disorder". We are told that: "Vitamin D levels were requested alongside standard admission blood tests on serum samples collected by venepuncture." Sounds like a good call by all accounts.

Alongside noting those quite important numbers/percentages of vitamin D deficiency and insufficiency (see here for more information about the distinction), authors also reported that: "There were no statistically significant differences noted in mean serum 25(OH)D associated with gender, age or primary diagnosis." They did however mention that: "Mean serum 25(OH)D was higher in participants of White British ethnicity compared with those of other ethnic backgrounds" indicating that skin colour probably plays a role in vitamin D production/levels. A shocker indeed [2].

"At the current time, there is insufficient evidence to draw any firm conclusions regarding an association between vitamin D deficiency and non-musculoskeletal health outcomes, including mental illness. More research in the form of larger epidemiological and intervention studies are needed to investigate the association between vitamin D and mental health outcomes; indeed, randomised controlled trials are planned that will hopefully shed more light on this intriguing area in the future." Sorry about the large text grab noted in that last sentence, but the authors said it better than I ever could in terms of (a) being cautious about making any specific connections between vitamin D deficiency/insufficiency and 'mental illness' and (b) the value of supplementation (see here and see here) outside of just restoring vitamin D levels to where they should be.

That being said, there is a further scheme of work to look at drawing on data from other labels (see here for example). Remembering also that, minus too many sweeping generalisations, some of the other health issues that seem to follow a psychiatric label *might* also show some involvement with vitamin D [3] too...

----------

[1] Patel D. & Minajagi M. Prevalence of vitamin D deficiency in adult patients admitted to a psychiatric hospital. BJPsych Bull. 2018 May 2:1-4.

[2] Bonilla C. et al. Skin pigmentation, sun exposure and vitamin D levels in children of the Avon Longitudinal Study of Parents and Children. BMC Public Health. 2014;14:597.

[3] Lu L. et al. Association of vitamin D with risk of type 2 diabetes: A Mendelian randomisation study in European and Chinese adults. PLoS Med. 2018 May 2;15(5):e1002566.

----------

Depression and anxiety *associated* with autoimmune thyroiditis

The results of the systematic review and meta-analysis published by Eva-Maria Siegmann and colleagues [1] provide some further welcome peer-reviewed inspection of the idea that autoimmunity and psychiatric issues are not necessarily separate and independent.

Their specific focus on autoimmune thyroiditis - where the body fails to recognise 'self' as self and mounts an immune response against the thyroid and it's products - and depression and anxiety, is something that has been discussed previously on this blog (see here).

As per the 'systematic review and meta-analysis' status of this paper, the name of the research game was to collect up the relevant peer-reviewed science literature on this topic and produce a coherent 'where we're at' statement. Researchers trawled the various science portals "from inception through December 5, 2017" and eventually arrived at 19 studies fulfilling their criteria: "Case-control studies that reported the association between AIT [autoimmune thyroiditis] and either depression or anxiety disorders." The combined participant number was just over 36,000 people - "(35 168 for depression and 34 094 for anxiety)".

Results: "We found that the chance of developing symptoms of depression that were of clinical relevance is 3.5 times higher among patients with hypothyroidism compared with healthy controls." And: "We found that the chance of developing anxiety disorders is more than 2 times higher among patients with hypothyroidism compared with healthy controls." Hypothyroidism by the way, refers to when the thyroid doesn't produce enough hormones, and is typically the end-result of autoimmune thyroiditis.

The authors also put their findings into some kind of population perspective: "3% of the US population (approximately 9.7 million people) has depression and 5.4% of the US population (approximately 17.5 million people) has anxiety disorders concomitantly with AIT. Thus, 45.5% of depressive disorders and 29.8% of anxiety disorders are associated with this endocrine disease." I don't mind telling you that, based on the currently available research data, those statistics seem to be pretty important. Not least that as and when depression and/or anxiety are diagnosed, physicians could do well to screen their patient for such thyroid-related issues as a first measure.

Of course, there is more to do in this area as the authors note. Not least is some further investigation with regards to the possible biological mechanism(s) through which AIT might act upon the presentation of such psychiatric issues and whether treating/managing AIT could impact on the presentation of depression and/or anxiety.

But yet again, we have further evidence that the [various] actions and effects of the immune system seem to have some important effects on behaviour, mood and wellbeing.

----------

[1] Siegmann E-M. et al. Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis. JAMA Psychiatry. 2018. May 2.

----------